Healthcare Provider Details

I. General information

NPI: 1962407833
Provider Name (Legal Business Name): DR. ROGER T. L. WONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 S BERETANIA ST STE C117B
HONOLULU HI
96813-2287
US

IV. Provider business mailing address

50 S BERETANIA ST STE C117B
HONOLULU HI
96813-2287
US

V. Phone/Fax

Practice location:
  • Phone: 808-538-6522
  • Fax: 808-538-1641
Mailing address:
  • Phone: 808-538-6522
  • Fax: 808-538-1641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1290
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: